Provider Demographics
NPI:1013483023
Name:KSA YOUTH FOUNDATION INC.
Entity Type:Organization
Organization Name:KSA YOUTH FOUNDATION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WILKINS-JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:240-766-4194
Mailing Address - Street 1:10905 FORT WASHINGTON RD STE 105
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5844
Mailing Address - Country:US
Mailing Address - Phone:240-766-4194
Mailing Address - Fax:301-485-0363
Practice Address - Street 1:10905 FORT WASHINGTON RD STE 105
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-5844
Practice Address - Country:US
Practice Address - Phone:240-766-4194
Practice Address - Fax:301-485-0363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-17
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD132375000Medicaid